NPIMap

Organization Active NPI

Brevard Orthopaedic Spine and Pain Clinic, Inc

  • Pain Medicine (Physical Medicine & Rehabilitation) Physician
  • Merritt Island, FL
National Provider Identifier
1124311501
Registry record updated Jul 15, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pain Medicine (Physical Medicine & Rehabilitation) PhysicianTaxonomy code 2081P2900X
Legal business name
BREVARD ORTHOPAEDIC SPINE AND PAIN CLINIC, INC
Practice address
650 S Courtenay Pkwy
Suite 100
Merritt Island, FL 32952-4977
Phone
(321) 723-7716
Fax
(321) 723-0604
NPI assigned
May 18, 2011
Organization subpart
Yes
Parent organization
BREVARD ORTHOPAEDIC SPINE AND PAIN CLINIC, INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 15, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Katrina Lopez
Title
Credentialing
Phone
(321) 541-1537

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Orthopaedic Surgery PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207X00000X
Pain Medicine (Physical Medicine & Rehabilitation) PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2081P2900X Primary

Addresses

Primary practice location

650 S Courtenay Pkwy
Suite 100
Merritt Island, FL 32952-4977

Mailing address

2222 S Harbor City Blvd
Suite 610
Melbourne, FL 32901-5594
Phone (321) 723-7716

Other identifiers 2

IdentifierTypeStateIssuer
99949OtherFLMEDICARE
040225700MedicaidFL

Other names 1

  • The BACK Center Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Brevard Orthopaedic Spine4 organizations share this tax ID, including this one
Part of
Brevard Orthopaedic Spine

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Locations

205 E Nasa Blvd
Melbourne, FL 32901
Phone (321) 361-5626

650 S Courtenay Pkwy
Ste 100
Merritt Island, FL 32952
Phone (321) 260-2101

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1305676800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1626307200000",
    "number": "1124311501",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2222 S HARBOR CITY BLVD",
            "address_2": "SUITE 610",
            "city": "MELBOURNE",
            "state": "FL",
            "postal_code": "329015594",
            "telephone_number": "321-723-7716",
            "fax_number": "321-723-0604"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "650 S COURTENAY PKWY",
            "address_2": "SUITE 100",
            "city": "MERRITT ISLAND",
            "state": "FL",
            "postal_code": "329524977",
            "telephone_number": "321-723-7716",
            "fax_number": "321-723-0604"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BREVARD ORTHOPAEDIC SPINE AND PAIN CLINIC, INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "BREVARD ORTHOPAEDIC SPINE AND PAIN CLINIC, INC",
        "enumeration_date": "2011-05-18",
        "last_updated": "2021-07-15",
        "certification_date": "2021-07-15",
        "status": "A",
        "authorized_official_last_name": "LOPEZ",
        "authorized_official_first_name": "KATRINA",
        "authorized_official_title_or_position": "CREDENTIALING",
        "authorized_official_telephone_number": "321-541-1537"
    },
    "taxonomies": [
        {
            "code": "207X00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Orthopaedic Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2081P2900X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physical Medicine & Rehabilitation, Pain Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE",
            "identifier": "99949",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "040225700",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "The BACK Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "The BACK Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Merritt Island, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 15, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.